Respect, a fundamental ethical attitude in medicine
Gonzalo Herranz.
Inaugural lecture of the 1985-86 academic year at the University of Navarre.
Pamplona, 3 October 1985.
For a long time, practically the entire period preceding the finding of antibiotics, doctors' possibilities for effective action were very modest. Their ability to help the sick was measured not so much by the meagre curative power of a few remedies, which had more of a placebo effect than a real pharmacological-molecular action, but by their mastery in administering simple psychotherapy, free of fear, and, above all, by their concern, full of humanity, for the dignity of their patients.
Today, the situation is very different. Over the last forty years, the curative power of doctors has grown steadily. Medicine has succeeded in conquering almost all infectious diseases; it has so lengthened the life span of men average that some are beginning to be alarmed by the demographic prevalence of the elderly. Medicine has established open-heart surgery and organ transplants as routine; it has turned pharmacology into an almost magical activity in which the intelligent design of molecules allows cellular functions, including neuronal ones, to be regulated almost at will. Medicine's latest adventure, the artificialisation of human reproduction, has people's mouths hanging open in amazement.
The doctor's responsibility is now much greater than before, because his or her power is also much greater. So much does medicine mean, in economic terms and in terms of its capacity to shape society, that it is necessary to ask whether doctors' technical progress is accompanied by a parallel refinement of their ethical sensitivity; whether their growing mastery of the biological is associated with a proportionate care for the dignity of their patients.
It is precisely in this area of the ethical responsibility of medicine that the topic of this morning's lesson is situated. I would like to discuss with you respect as a fundamental ethical attitude in medicine. There is no shortage of people who maintain that each profession has its own specific ethics1. Judging from the Codes and Declarations that guide the conduct of physicians, respect seems to be one of the essential components of the professional ethics of medicine. But it is like certain books - Don Quixote, many classics, the writings of John Paul II - which are much talked about but unfortunately little read: the frequency with which respect is cited in many solemn documents contrasts with the scant attention paid to it in passing in a small number of studies.
It so happens that little has been written on respect in medicine and I have only been able to access a fraction of the bibliography. It is precisely for this reason that I have decided to bring here topic, in order to provoke curiosity and, if possible, collaboration among colleagues and listeners. I hope that doctors and theologians, biologists, jurists and philosophers can help me, with their data and suggestions, to enrich the doctrine of this lesson that I offer you today in outline.
Respect in contemporary medical-ethical documents
When one reviews contemporary medical ethics documents, one soon discovers that, in Codes and Declarations, respect is cited as one of the physician's fundamental obligations. This was not always the case. Neither the medical-ethical texts of antiquity (the Oaths, the Prayers or the lists of commandments or counsels)2 nor the medieval writings, nor the treatises on medical ethics of the Modern Age3 , make specific reference to respect. It seems, therefore, that in medical ethics, respect represents a late acquisition, an attitude of our own time.
A systematic and rigorous review of topic would be necessary, but I have the impression that it is in the Geneva Declaration of 1948 that respect as a fundamental ethical attitude in medicine is first mentioned4. A more solemn presentation of respect in society could not have been chosen. The Declaration of Geneva is the illustrious cradle of modern medical ethics. Promulgated by the then newly constituted World Medical Association, it contains nine pledges which translate into modern language the clauses of the Hippocratic Oath. Three of these nine pledges speak of respect. They read:
"I will pay my teachers the respect and gratitude I owe them", "I will respect the secrets entrusted to me" and "I will maintain the utmost respect for human life from the moment of conception".
From the moment of its promulgation, the Declaration of Geneva, and with it the ethical significance of respect, gained universal acceptance. Thus, the obligation to respect appears in national codes of medical ethics and in ethical guidelines issued by supranational bodies or international associations. It would be too long to cite here the texts from the most diverse cultural areas that include respect among their ethical norms. But, by way of example, I can only list a few to illustrate their universality and content.
The Code of Medical Ethics now in force in Spain5 cites the word respect in five articles. It tells us that "respect for life, for the integrity of the human person, and for the health of the individual and of the community, constitute the primary duties of the physician" (Art. 5.0). The doctor, says Article 24, "shall always respect the religious, philosophical and political convictions of the patient or his or her relatives". Article 60 states that "It is an ethical requirement that physicians treat each other with due deference and respect, whatever the hierarchical relationship between them". Speaking of the right of patients to free choice of doctor, Article 12 states that "as far as possible, the wishes of the patient shall always be respected".
. The Barcelona Doctors' Ethics Regulations of the high school de Médicos de Barcelona6 impose practically identical precepts, but state with particular force in Article 5 that "The most scrupulous respect for life and all the rights of the person must constitute the first ethical attitude of the professional conscience".
Article 1 of the Medical Ethics Regulations of the Colombian Medical Federation of 19817 will sound particularly pleasing to our Navarrese ears. It reads: "Respect for life and the rights of the human person constitute the spiritual essence of medicine".
I would just like to add two more texts, from what could have been a very long anthology, as they seem to me to be particularly demonstrative. The first comes from the Code of the Nurse8 C by the committee International Nurses and illustrates the profound identity of ethical ideals between the different health professions. These are its words: "Inherent in nursing is respect for the life, dignity and rights of man, respect which is not limited by considerations of nationality, race, creed, colour, age, sex, politics or class ". The second appears in the Preface to the European Guide to Ethics and Professional Conduct, drafted by Professor Lortat-Jacob, which was adopted on 14 January 1980 by the International Conference of Medical Orders and Similar Organisations9 . This document defines on the one hand that "The practice of medicine has as its purpose the protection of the physical and mental health of man and the relief of pain, with respect for life and the human person and without discrimination as to race, religion, nationality, social status and political ideology, in time of peace as in time of war". For Lortat-Jacob10 , the ethical notion of respect informs the whole of medical ethics and has such force that it is sufficient to prohibit certain actions that are contrary to it, to establish the indispensable trust of the patient in his doctor, to demand the independence of the doctor in his diagnostic and therapeutic actions, whatever the modalities of his professional practice and, finally, to impose on himself the obligation of the professional skill .
Since its proclamation as one of the ethical components of the Geneva Declaration of 1948, respect has gained an increasingly prominent place among the ethical values of medicine in the almost 40 years since then. Today, as we have just seen, it is regarded as the primary duty of the physician and the first ethical attitude of the professional conscience; it is exalted to the spiritual essence of medicine, or is constituted as source from which all other duties and prerogatives of the physician flow.
Because all these very abstract expressions are rather a reflection of the general ethical environment, of the ethos of the profession, than result of a critical and rigorous philosophical analysis11 , one must ask oneself the reasons for such a great splendour. Why has respect made such a rapid and triumphant career? There are certainly many explanations, but in my opinion, the fact that respect, being a Christian concept in its origin and structure, has the capacity to circulate as a secular ethical value of great attractiveness and acceptance, has played a decisive role in the rapid promotion of respect.
Respect, a secular formula for a Christian concept
This is not the place to present a solidly documented argument in favour of the thesis I have just stated. To investigate the matter properly would require a lot of systematic work and the skills and the official document, which I lack, of the theologian, the philosopher or the jurist. I will confine myself to pointing out a few points of reference that will help to underpin the idea.
First, I would like to refer to a historical coincidence. The Declaration of Geneva was adopted by the World Medical Association in September 1948. Three months later, in December, the Universal Declaration of Human Rights was adopted by the United Nations General Assembly12. It is clear that there are deeper relationships between the two Declarations than mere chronological coincidence. Both take elements from the past that are deeply rooted in Christian thought and society, strip them of their religious connotations, i.e. secularise them, and offer them to the world as a programme of universal validity.
Let us take a closer look at this process of secularisation with regard to the Declaration of Geneva, which obliges us to study it in parallel with the Hippocratic Oath. Indeed, the Declaration was conceived as a substitute for the Oath and was offered to doctors all over the world, and in particular to medical schools, as a new ceremonial formula, by which young graduates could commit themselves to the most fundamental ethical principles of the profession13.
It is indisputable that the transformation of the Oath into a Declaration was justified for simple stylistic reasons: the now archaic expressions of the venerable document needed to be translated into modern language14. The Oath was in need of a textual update, as it had become meaningless to physicians in the second half of the 20th century. But the men who drafted the Declaration of Geneva were not motivated by mere scruples of lexical propriety. The Declaration represents above all an attempt to make acceptable to all the world's physicians - of a world that is both secularising and integrating into a functional unity - a core of ethical ideals which, on the one hand, are consistent with the noble traditions of the past and, on the other hand, aspire to point out the guidelines for the professional conduct of the future.
This secularising and universalist intention explains why the new formula is no longer an oath, but a promise. Instead of swearing, as the old one did, by the god of health, Apollo, and by Asclepius, by Hygieia and Panacea and by all the gods and goddesses; or of putting God the Father, Son and Holy Spirit as witness to his oath, as the Christian doctor did, the new doctor makes his promises "solemnly and freely and on his [word of] honour".
The Declaration thus modernises the text, while retaining the spirit of its precepts, and replaces the old religious framework with a new, secular one. In doing so, it ensured its almost universal acceptance: on the one hand, the exclusion of any reference to religion pleased agnostics and avoided disputes between professionals of different faiths; on the other hand, it did not repulse believing doctors, as it prescribed a reverent attitude towards the sick person, of unmistakably religious inspiration.
It is precisely the secularisation of the ethos of medicine, which the Geneva Declaration has brought with it to all corners of the world, that is the main factor responsible, in my opinion, for the progressive rise of respect to the forefront of ethical attitudes in medicine today. And this promotion, as well as the universal acceptance of the Geneva Declaration, is based on the dual character of respect as an ethical attitude: it is a secular formula for a Christian concept. This was sufficient for its acceptance by all.
Some have told me that respect is, in Ethics, a product of modernity; that there is hardly any written history of respect prior to Kant; that the ancients certainly took it for granted that man has a higher dignity and a unique position in the world, by virtue of which he is worthy of honour and respect, but that they never referred to respect by this name. It is obvious that respect is not a new principle in either religious or philosophical ethics, for it has always been active as the central meaning of the commandment to love one's neighbour15. Donagan has pointed out that the philosophical core of morality in the Judeo-Christian tradition, i.e. that which is not directly dependent on explicitly monotheistic faith, can be condensed into this principle: It is not permissible not to respect the human being, whether self or other, as a rational creature. Donagan himself thinks that all other moral principles and rules of Judeo-Christian morality can be derived from this fundamental principle16. From a more historical-medical than philosophical perspective, Laín points out how Christian love of neighbour, the foundation of Christian friendship and of the doctor-sick relationship in a Christian context, is mutated into the respect of secularised friendship and concludes that the Achtung of the exquisite Kantian theory of friendship is nothing but the secularisation of the Christian attitude towards the "sacredness" of the neighbour17 .
I do not think it necessary here to make any effort to prove how, in the ethical tradition of the Old Testament, respect for man forms a considerable part both of the commandment to love one's neighbour and of the biblical anthropology of man created in the image and likeness of God. Moreover, we all know well that respect for man culminates in the New Testament in the central dogma of the Incarnation: by taking flesh and dwelling among us, Christ became the brother of every man; by redeeming us on the Cross, He has configured us to Himself and restored to us with sanctifying grace the supreme dignity of God's adopted children. In Christ the "deification" of man is made possible, and it is precisely for this reason that man becomes worthy of absolute respect.
In the analysis of the relationship between charity, respect and the practice of Christian life, I believe the contribution of Bishop Josemaría Escrivá de Balaguer to be very important. The Founder of our University is the author of a homily with the significant title "Christian respect for the person and his freedom". Here are some words of his that are extraordinarily full of content: "Christian charity is not limited to helping those in need of economic goods; it is directed, first of all, to respecting and understanding each individual as such, in his intrinsic dignity as a man and as a child of the Creator.
Let us now turn to the question: What is the consequence for the ethics of the physician of transferring the old wine of Christian respect into the new wineskins of secular ethics? This is the big question we have to ask ourselves. In order to be able to answer it adequately, we must first turn to a previous question, which I cannot postpone any longer: the structure and function of respect as an ethical attitude.
What is respect as a fundamental ethical attitude?
When we talk about respect for life and the integrity of the human person, what do we really mean? Many people think that respect has to do with polite propriety, with keeping the conventions of civility. Such displays of politeness are very important, because they show a willingness to appreciate certain cultural and social values that make living together bearable, or even pleasant. The respect owed to the patient by the physician includes, but is not limited to, these conventions. The doctor must be correct in his treatment and dress, and also be attentive and punctual with his patients, because he is obliged to behave like a person of the high level of education that is expected of him. Because of the particular situation of vulnerability of each patient, casualness, irony or arrogance are out of place in the doctor-patient relationship. There are some studies on the ingredients of the polite respect that the doctor owes to his patient. Richmond distinguishes between respect for identity, which is the basis of a physician's personal relationship with his patient and which tends to create the figure of the physician-friend; respect for privacy, which includes the private nature of enquiry, modesty in physical examination, and professional secrecy; and finally, respect for time, minimising unavoidable delays in personal patient care19 . In this last component of polite respect, Benarde and Mayerson have included, as an essential element of the doctor-patient interaction, the obligation to show respect by responding to the patient's questions and also to his or her non-verbal messages20 .
These aspects of polite respect are not irrelevant to understanding the ethical dimension that interests us, for to some extent they prefigure it. Crawshaw has described how respect can become engrained in our spirit as a result of repeatedly experiencing that the weak matter too. For its value educational for the medical student and the young physician, I transcribe these lines of his: "The idea that the weak are important.... may cross the mind of a girl when she suddenly realises that saying 'please' is not a mere formality her mother imbued her with, but a subtle exchange of appreciation with another person, or a boy, who suddenly realises that opening the door for an old man is not a heavy duty, but realises that the time and effort spent are a gift he has given to himself and to the old man. These atoms of social sensitivity, the realisation that the other person, though weak, has feelings and needs, may be fleeting experiences. But they are also the buds that mature into respect; they are the raw subject of human behaviour, the initial capacity to understand that I can always choose between what is best for myself alone and what is best for the other person and for me "21.
From these humble principles germinates the practice of respect. But respect as a fundamental ethical attitude is much more than good manners. It is the centrepiece, something like the nervous system, of the ethical organism. Moral life depends, in its abundance and quality, on the ability to grasp moral values. And we only achieve this when our ethical sensitivity is attuned by respect. Just as sensory deprivation impoverishes, sometimes to an extreme degree, the intellectual development , so blindness to moral values impedes man's ethical development .
But respect is not simply a sensory apparatus for perceiving moral stimuli: true respect is a high-precision apparatus that integrates moral stimuli into a real image, free of aberrations, faithful, therefore, to what things are in themselves. Respect leads us to recognise that other beings are something valuable in themselves, that they exist independently of the person of the observer, that they have a value of their own. Respect is a powerful inhibitor of capricious manipulation, of the falsification of valuable data. Respect inoculates me against ethical subjectivism. Therefore, the respectful man knows that he is not the master of the world, graduate to assess the value of ethical values at any given moment, making them depend on the situation of the moment.
Moreover, respect is not only the condition of the intelligent and profound knowledge , the sensory and integrative apparatus of moral consciousness: it is also its effector organ. In accordance with the information processed, it responds with respectful action, i.e. appreciative of and proportionate to objective values. Respect makes it possible that the response to ethical values can take the form of intelligent, not servile, but reasonable subordination. The willingness to serve is usually part of the behaviour of the respectful person, but not as a timid abdication, but as a lordly response to the value enclosed in things and, above all, in people.
Subjectivist ethics suffer from a lack of respect. Their disconnection with the world goal of being and ethical values extinguishes the light that illuminates the universe of the authentic and destroys the control mechanisms that, in respectful moral life, prevent the opportunistic manipulation of moral data and values.
Dietrich von Hildebrand, from whom I have taken and reinterpreted the gist of what I have just said about the structure and functions of respect, states that this fundamental ethical attitude is the mother of moral life, thanks to which man adopts a position of openness towards the world that enables him to perceive, accept and respond to objective moral values22.
Respect for human life in the Hippocratic tradition
The touchstone of ethical principles is their operability, their capacity to inspire good deeds, to promote the beneficence of moral agents. We must therefore ask ourselves how does respect work in practice, what is its validity? To answer these questions, we need to define a field of examination. The Codes tell us that the doctor must respect human life, the biological and personal integrity of his patient, his freedom of choice and his legitimate demands. To consider, even in passing, all these districts of respect would make these considerations intolerably long. We will find a short and practicable way if we limit ourselves to analysing respect for life: it is the best yardstick for taking the measures of respect in the doctor's practice, especially today, when the value of human life is at a premium at leave.
To put topic in perspective, let us go back to the time before the Geneva Declaration. Before 1948, although there was little talk of respect, the practice of medicine was steeped in what might be called the "ethical equivalent" of respect for life. The physician taking the Hippocratic Oath undertook the following commitments: "I will not give to anyone lethal drugs even if he asks for them, nor will I suggest their use to anyone. Nor shall I administer to a woman an abortifacient treatment, for I shall practice my art throughout my life in purity and sanctity". These words, with their venerable solemnity, express precisely the commitment to respect human life, to abstain from the practice of euthanasia and abortion.
Let us consider how this attitude includes the elements - perception, acceptance, response - of respect in relation to human life.
The Hippocratic physician is obliged to be an expert in perceiving human life, he must also possess in his mind a visual acuity that allows him to discover it under all its pleomorphic appearances. He perceives it in the healthy as well as in the suffering, in the old man as well as in the child, in the embryo no less than in the adult at the height of his fullness. They are all human lives, enjoyed by human beings, supremely and equally valuable. Whatever these human beings may lack in size, intellectual wealth, beauty, physical vigour, whatever they lack, the physician makes up for with his knowledge and his art. Because, as Hippocrates says, "where there is love of art, there is love of man "23.
Perception is followed by acceptance. The physician not only regards everyone as equal: he or she is committed to being equally generous to all who come to him or her. This commitment is not born not from the physician's being an activist for the right of all to health and medical care, but from the recognition of the unique and irreplaceable value of every human life. Every human being - and this was known to physicians before Kant taught it - is valuable in himself or herself, independently of any other consideration. In this sense, and culminating a historical process of non-discriminatory service to the wounded, of which the Knights Hospitallers of St. John wrote the first, somewhat crooked but legible, lines, we find the singular fact of the elevation of the physician to the status of non-belligerent on the battlefield. The First Geneva Convention, in order to make it possible for the doctor to treat the war wounded, not according to the side on which they are fighting, but only according to the medical emergency, segregates the doctor from the number of combatants and confers on him a status of neutrality so that he can exercise his official document of curing, totally different from the official document of wounding24. In peace, a deontological precept that is not lacking in any code establishes that the doctor must accept all those who come to him enquiry or, at least, must refer to a colleague those who, for whatever reason, he cannot or does not wish to treat25.
Lastly, respect enables one to respond to the highest value of every human life. The Hippocratic doctor submission is committed to the cure, preservation and rehabilitation of his patients, and when he is unable to cure, to the very important and demanding operations of high professional standards of palliative relief and consolation. It is also responsible for the protection of the personal values of people weakened or incapacitated by illness. It is here that the function of substitution to which I alluded a moment ago takes on its greatest importance. The weaker or more defenceless the patient, the more attentive and punctual, and also the more competent and scientific, the intervention of the physician must be.
These are the extent and intensity of respect in the Hippocratic ethical tradition. The behaviour thus depicted may seem to us to be an idealised, unrealistic picture. Some may argue that flesh-and-blood doctors tend to be somewhat cynical, with a conscience and sensitivity calloused by their habituation to seeing human suffering as routine, and that they do not aspire to such high ethical perfection. It is worth noting in this regard that the ideals that inspire the physician's conduct in the Hippocratic tradition are taken very seriously. For even if the actual conduct of physicians falls, not infrequently, below the high moral standard to which they are expected to conform their lives, at least the physician is always aware that the ethics he has embraced impose certain absolute duties upon him. The ethics imposed by the Oath are categorical ethics. It is often necessary to remind the man of our day - this was Robert Bolt's purpose in writing his famous drama about Thomas More - that an Oath makes absolute the content of promises made and that, in swearing, a man puts his own identity at stake as a pledge of the firmness of his convictions.26 The Oath is an oath that is not only a pledge of his own identity, but also a pledge of the firmness of his convictions.
Thus, the Hippocratic Oath is not a ritual formula for admission to a guild in order to pledge the neophyte's institutional fidelity. In its Christian version, it is a true oath by which the physician makes God a witness to his or her free decision to embrace precise conduct in relation to the ethical core of his or her work. By taking an oath, therefore, the physician proclaims that his or her professional conduct will not be at the mercy of considerations of personal convenience or at the whim of human-made situational factors. The physician freely decides to carry out his work in accordance with God's supreme designs for man, and in so doing he removes from himself any temptation to dominate his fellow man or to serve any master other than the sick man himself. At summary, the Oath establishes that medicine is an ethical activity practised under the gaze of God.
In what concerns us specifically this morning, the Oath firmly anchors in the physician the notion of the inviolability of all human life, of its sacredness.
Respect for human life since the Geneva Declaration: The history of an abdication
The Declaration of Geneva of 1948 makes the physician who assumes it pledge, inter alia, the following obligations: 'I will maintain the highest respect for human life from the moment of conception and, even under threat, will not use my medical knowledge contrary to humanitarian laws. In the immediately preceding clause, the physician undertakes to exclude any discrimination in the treatment of his patients with these words: "I will not allow considerations of religion, nationality, race, party politics or class to come between my duty and my patient.
Not 40 years have passed since the text of the Declaration was promulgated to inform the practice of medicine today. And it is with regret that we note that in many places the highest respect for life no longer inspires the conduct of physicians. Largely due to the acceptance by large sections of humanity of abortion as ethically neutral, the ethos of medicine has changed radically. The categorical attitude of respect for life has been abandoned by not a few doctors and replaced by a relativistic one, which makes ever wider cuts in the list of human beings deserving of that unconditional respect. Such doctors no longer treat their patients in the same way: some are flattered, others are suppressed. Discriminatory criteria vary from place to place, but what is really important is that the notion that all men are equal before the doctor is gradually dissolving in the consciousness of these doctors and of the society they serve.
These changes would not have been possible, at least not with the tremendous speed with which they have occurred, without certain circumstances. I will pay attention to only two that seem to me to be of particular relevance. Firstly, the skilful adulteration of language, which has allowed the manipulation of the content of real data and ethical precepts. The astute handling of new persuasive formulas has made it possible, thanks to the experience gained in commercial advertising and political propagandism, to introduce into the masses, in an atraumatic way, new expressions that make tolerable, fashionable or necessary what was previously rejected as repugnant or unworthy27.
In the demolition of the concept of the inviolability of life, the technique of persuasion that Sosnowski has called semantic gymnastics28 has been thoroughly employed. Just as gymnastics, through the repetitive practice of certain movements, makes it possible to acquire certain skills, thanks to a barely perceptible increase in directed effort, so the introduction and acceptance of new intellectual and ethical attitudes can be achieved by an indoctrination that has the same programmed, gradual and directed character as the gymnastic plank. For example, so that no woman has to acknowledge the fact that by having an abortion she has destroyed an innocent and unrepeatable human life, certain terms are created which are fallacious and unacceptable, but which are easily swallowed by their technical appearance which does not raise moral suspicions and which anaesthetises ethical sensibility: they speak of "menstrual extraction" and "menstrual regulation", thus concealing from the eyes of conscience the dramatic immorality of the destruction of a human embryo. This is representative of what is happening in today's permissive society, where hardly anyone teaches anyone to be responsible for their own behaviour any more. The social acceptance of the new morality has been facilitated by the change of meaning of a number of ethically loaded terms, such as contraception, abortion or euthanasia, through semantic mutation. The new words are presented not only as ethically neutral, but surrounded by an aura of innocence: contraception, voluntary termination of pregnancy, death with dignity are not simply synonyms of the old words. They are neologisms with a deliberately manipulated ethical meaning. One day philologists will tell the story of this tremendous swindle to which a large part of society has lent itself with far from innocent complicity.
Secondly, the demolition of the concept of the inviolability of life has been contributed to by the harsh attack on its weakest flank: the beginning of human life. It is alarming to see how, without any scientific support from test , the beginning of the individual is moved from the moment of fertilisation of an oocyte by a sperm to the moment when the embryo completes the nesting process. In the past, a book on embryology could state with the simplicity of observational data: The life of a new individual begins with fertilisation29. From now on, new treatises will have to overcome certain taxonomic conflicts: it is no longer clear where a new human being begins to exist. Before telling us the history of the human organism development , they will have to tell us a prehistory: that of the first two weeks of the existence, as brief as it is brilliant, of a new being, which, logically, will have to be called from now on not a human embryo, but simply a pre-embryo. A persuasive denomination of this cut tends to hide its human condition. It is not appropriate to admit the pre-embryo into the human family. It is not because it lacks continuity with the adult human being it is on the way to becoming, or because between the 14th and the following day there is a leaping phenomenon, a biological or ontological discontinuity, which takes the tiny being from a non-human, pre-human or sub-human level to a fully human one. Between the 14th and 15th nothing happens that can be compared in importance to what happened in the previous days, in which the new organism has had to make more momentous decisions than in the rest of its biological existence. For some, the curtailment of a pre-human period, in which the so-called pre-embryo will no longer be worthy of respect, is the answer to the functional need to resolve a dilemma that troubles them: the moral conflict that arises from the fact that certain contraceptive procedures (both pharmacological and intrauterine devices) function as abortifacients. The public disgust that this eventuality might create would undoubtedly threaten the social acceptance - and, eventually, the commercial profit - of such contraceptive methods. To save the moral suffering that such early abortions could induce, no transcript is more effective than depriving the human embryo of its human condition. The conniving credulity of the man and woman in the street accepts that neither a "cellular mass of a few tenths of a millimetre" nor a "small globule of jelly" or a "pre-embryo" can possess human nature.
But the permissive man of science is not free to accept this mythologisation and insists on rationalising his wish that the human embryo does not attain human status until after the first two weeks of its life. Such an arbitrary idea is, by repetition, becoming a majority opinion. The peremptory need for research on human embryos to improve the leave performance rate of in vitro fertilisation techniques has become an argument of enormous persuasive force in the scientific community: whoever thinks of dissenting is branded an insensitive fundamentalist who does not deserve to be part of the family of scientists30.
The combined environmental pressure from the legitimisers of abortifacient contraception and the advocates of human embryo research has weighed heavily on the World Medical Association, to such an extent that the Association's General Assembly in Venice in 1983 was forced to make a change in the text of the Declaration of Geneva. The clause "I will maintain the highest respect for human life from the moment of conception" was changed to "I will maintain the highest respect for human life from the moment of its beginning". Logically, it was left to the free decision of doctors and legislators to determine the moment at which each one considers that human life begins. The same literal change had to be made in the text of the Oslo Declaration of 1970, in which the World Medical Association condemned abortion. Since the Venice Assembly, the Declaration of Oslo, the most equivocal of the Association's products, demands of physicians the utmost respect for human life from its beginning, no longer from conception, and states that physicians must accept that there are, in fact, different attitudes towards the unborn child, attitudes which, as a matter of individual conviction and conscience, must be respected31.
We see how the maximum respect of 1948, while remaining identical in form, tends to vanish, and Withdrawal to the protection of human embryos. This abdication was not dictated by scientific principles or convictions. It was imposed by social consensus, by the need to bring the Declaration into line with the new situation created by legislation permitting abortion and by the massive practice of contraception. The World Medical Association, hitherto the bastion of Hippocratic ethics, was unable, despite its firm resistance, to prevent the massive onslaught of ethical relativism born of permissive legislation. Let us consider the fact that an abortion law changes, overnight, what was once a crime into something that takes on the appearance of legality. For, unfortunately, the strictly legal-penal change brought about by decriminalisation is transformed, in a very short time, into a general conviction of the ethical neutrality of the decriminalised act. In this way, ethics, dragged along by the law, becomes something relative, changeable, not absolute. As, moreover, the image of man tends to be configured on the coordinates established by laws and ethical practices, man goes from being an absolute value in himself to becoming a relative value, which is no longer worthy of unlimited respect.
The effects of this depreciation are felt first by the weakest.
Our younger siblings
An ontological remodelling is taking place: human embryos, the smallest of our brethren32 , are being dispossessed of their human condition and degraded to things. This is done, as I pointed out a moment ago, in order to ethically justify research on human embryos. It is not easy to systematise the different opinions as to whether or not such a practice is acceptable, for what reasons, under what conditions of scientific or institutional control, to what specific problems it could be applied, or whether there is an age limit for embryos beyond which experimentation is no longer licit. Therefore, let us limit ourselves to considering a few arguments.
For many, a discussion in the light of ethical principles is superfluous: it always inevitably leads to debatable conclusions. There is, we are told, an easier logic to understand: that of sticking to the facts. More than a thousand test-tube babies have already been born, they continue: anyone who rejects embryo experimentation would have to admit that all the pioneering work of in vitro fertilisation that culminated in the birth of these babies was an ethical mistake. agreement It is doubtful, they conclude, that the mothers of these thousands of children, once desperate and now happy thanks to science, can agree with those who oppose the extension of this happiness to a much larger number of women, which can only be achieved by continuing embryo experimentation33 . This subject of arguments is clearly intended to intimidate: those who dissent from it are portrayed to the public as being without compassion and disloyal to the progress of science. It is not surprising, then, that such arguments have taken over much of the battlefield. Medical ethics is coming under the domination of the reductionist or sociological mentality, of the ethics of facts and consensus. In meetings to discuss the ethical aspects of new technical acquisitions, it is not unusual to demand the surrender of dissenters, using, of course, the good manners of persuasive language. Something along these lines: "Everyone recognises that the embryo is entitled to certain moral demands AND that society feels a duty to protect embryos against certain events. But this duty is yet to be determined, as are the rights of the embryo. Faced with this changing situation, the moralist's duty is to submit to the facts".
plenary session of the Executive Council In the face of this mentality, it does not seem futile to argue that human embryos are simply embryonic human beings, that they possess moral claims not because society grants them, but because of the primordial fact that they are rightful members of the human race; that embryos are not incorporated into the human family by a kind of selective adoption, whereby some are accepted and others rejected; that embryos are not incorporated into the human family by a kind of selective adoption, whereby some are accepted and others rejected; that their rights are not granted to them by a discretionary decision of the other members of the social , but that society is obliged to recognise the identity, nature, and individuality of every other new member of it and that he or she is natively and certainly entitled to be protected by law34. And it is necessary to insist strongly on these reasons, because the sociological vision denies that the embryo is someone who demands in itself the highest respect: what it takes is to grant it a restricted measure of value, from with the consensual estimation of some Committee appointed for this purpose. group agreement
It is interesting to take a closer look at the recommendations of some Committees concerning experimentation in human embryology. The British Committee chaired by Baroness Warnock35 has granted the human embryo a certain Degree legal protection, which is compatible with the authorisation to create embryos exclusively for research purposes. (The British Medical Research Council36 estimates that 2,000 to 4,000 oocytes could be obtained annually in the United Kingdom, as many women who undergo sterilisation operations would willingly donate oocytes to generate embryos for research). The Warnock Committee requires certain conditions to be met: the projects must be approved by a very demanding control committee; the limit of 14 days from the moment of fertilisation must not be exceeded; and the embryos researched must not be re-implanted in a woman's uterus, i.e. the death of the embryos used in the experimentation is obligatory.
On the other side of the Atlantic, the Ethics committee of the department Health, Education and Welfare37 considered that the human embryo is worthy of profound respect. It considered that research to improve in vitro fertilisation techniques was a defensible but controversial issue and that research should be terminated before day 14 of fertilisation. The US government rejected this conclusion of committee and since 1979 has neither subsidised nor allowed experimentation on human embryos in the US.
In Australia, the Waller Commission38 approved research on embryos up to 14 days old if it was exclusively aimed at improving the success rate of clinical IVF programmes, but considered the production of embryos for research purposes morally unacceptable, as it would amount to using a "genetically unique human entity" as a mere means to an end.
The examples could be multiplied. There are strongly restrictive guidelines (those of the German Chamber of Physicians39 , for example) and others that are remarkably permissive (the recommendations of the English Medical Research Council36 , eager to retain British supremacy in this field). Some put respect for the embryo and the protection of its potential rights at the forefront. The others are guided in their decisions by the technological imperative. Judging by what is published, it seems clear that fewer are inspired by criteria of respect (what is, or rather who really is, a human embryo in itself?) and that more apply criteria of utility40.
The 14-day time limit is seen by some as a prudent compromise to bridge the differences of opinion between those who protect the embryo and those who wish to experiment unhindered with it. Others choose this time limit because, in their opinion, it marks the beginning of the individual development as signalled by the formation of the primitive line, the latter eventuality being an index, for others, of the initiation of the differentiation of the nervous system or of the differentiation of the embryo in general41. Recently, voices have been raised against the limit of 14 days, which is too restrictive, and proposals have been made to postpone it to around day 30, which is when electrical activity is first detected in the nervous tissue; or to day 40, because until then the sensory apparatus has not developed to Degree enough to perceive pain and, consequently, experimentation would not inflict physical suffering42.
Thus, the capacity not to see in the human embryo a human subject, to ignore in it the smallest of our brothers and, consequently, not to treat it humanely, admits a wide variety of nuances. The capacity for disrespect does not seem to be exhausted. Recently, someone has proposed an original and brilliant "solution" to certain practical problems of in vitro fertilisation: starting from the consideration that the embryofetal organism is, from a biological and immunological point of view, an allotransplant, he concludes that it does not seem incongruous to treat it as such from a legal point of view. The human embryo in vitro, equated to a human organ available for transplantation, can be offered, accepted, rejected, destroyed, i.e. treated as an object of transaction of agreement with the law of transplantation. The validity of this concept would be supported by the opinion of the US Supreme Court which since 1973 considers that human embryos are not endowed with established human life and also by the general acceptance of the idea by the public43 .
Some, with no little common sense, have wondered how it is possible that in the UK the same people who accept an abortion law that permits the destruction of a foetus up to the age of 28 weeks, propose approve legislation that limits the age of embryos undergoing experimentation to two weeks.44 There is a simple explanation: the value of the embryo, and the consequent allocation of rights or respect, seems to depend on what the guardians of society have in each case in view; abortion or fertility. There is a very simple explanation: the value of the embryo, and the consequent allocation of rights or respect, seems to depend on what the guardians of society have in each case in view; abortion or fertility. It is hard to find a more demonstrative example of ethical relativism making its way into legislation.
Rebuilding respect
We have just seen, with very contemporary data and arguments, the erosion in recent years of the fundamental attitude of respect. It is time to propose solutions. The first idea that may come to mind is this: in view of its unquestionable failure, both respect as an ethical attitude and the Geneva Declaration of 1948 itself should be scrapped and replaced by instruments more suited to the times, as technical progress and the new ethos of medicine seem to demand.
In my opinion, this is not the solution. It is not the solution, because invoking technical progress and the new morality defended by certain currents of opinion that claim to be authentic interpreters of the new directions of medicine as criteria for establishing ethical principles is tantamount to a declaration of innocence for all subject of medical progress and practice. But one thing is clear: for those of us who are involved in the analysis of the ethical currents of medicine today, it is evident that the practice of medicine is not - nor has it ever been - an innocent activity, or even an ethically neutral one. Until not so long ago, medicine was practised by some men for the benefit of other men. In recent years, and more and more intensively, it is done in the presence and under the control of the State. In any of these situations, neither one nor the other can fail to take sides in favour of some conception of man, and such a stance has immediate ethical effects; it is in itself a fundamental ethical choice. Thus, professional practice places the physician in a field of scientific, social and ethical forces from which he or she cannot escape.
From time to time, the fire of a permanent controversy is rekindled: the possibility of a Science or a Medicine free of values, that is, free of anthropological convictions or ethical commitments. Time and again, it is demonstrated that Science and Medicine, despite their persistent efforts to purify their methods and results of any extra-scientific connotation, will always and inevitably remain human enterprises, made by men whose opinions and beliefs, or lack of them, influence all phases of scientific endeavour: in the selection and funding of the topics to be investigated or most urgently addressed; in the ways in which problems are methodologically approached; in the language in which results and their consequences are reported; in the acceptance or rejection of their publication.
Medicine is intrinsically and inevitably an ethical activity. But it is also the case that the social influence of medicine today is so great that the doctor-patient relationship is no longer a matter that is confined to two people. What the doctor does has a decisive influence on the social ethos45 . Let us look at an example. A doctor's acquiescent attitude towards abortion on demand, towards libertarian abortion, consolidates in society the notion that human life, and in particular that of the child, is something of little value, disposable, replaceable. The child then competes, as just another factor in the cost and investment account, with other desirable goods within the budget, always strained by the needs that the advertising artificially creates. The child ends up being considered as an object whose acquisition can be delayed more or less indefinitely, as it is a permanent expense , which, once made, is no longer interchangeable and which forces one to do without many objects and some comforts. When the tension between standard of living and family programming reaches a certain level, the optimal number of children is zero46 . This is already beginning to be a threatening reality in the Russian Soviet Socialist Republic. This, however, cannot be achieved without the cooperation of the doctor, for to achieve this 'optimum' requires the full use of contraception and abortion.
Thus, since the practice of medicine is neither innocent nor neutral, physicians need, in order to maintain their professional integrity, to fully regain respect as a fundamental ethical attitude. Sometimes he will have to be the defender of the patient against the patient himself or against the family or society. At other times he will have to defend society against the abusive or irresponsible behaviour of pretenders and parasites. The physician, with his respect for life, for the integrity of the person and for the health of the individual and the community, is called upon to be a moral agent of the first order in society.
Many new students begin their studies today. For those who have chosen medicine, I assume they have an irrepressible and sincere vocation, as necessary to challenge the uncertain professional future as it is to keep alive the unquenchable thirst for knowledge that the absorbing Study program requires. Consequently, they will have to cultivate, together with their studies, their personal quality: to attend to their growth in human attitudes and values.
In the years to come, the tension between ethics and technical possibilities will become more and more strained. The doctor will then have plenty of opportunities to demonstrate the moral fibre of which he is made. Let us consider this in the light of an example47. Work is now in progress on the production and essay of a pill which is capable, by means of an ingenious combination of an antiprogesterone and a prostaglandin, of producing a kind of biochemical dissection of the placental attachment to the endometrium, thereby detaching the embryo up to at least 12 weeks of age and then expelling it from the uterus. There are those who hope that this achievement of pharmacology will put an end to abortion clinics. A woman will be able to have an abortion at home, as she will not need financial aid to do so. They are also confident that the new pill will eliminate the psychological after-effects that so often occur in women after the destruction of an innocent life. The significance of this abortion procedure is extremely important: it will establish as a socially accepted fact the notion that the human embryo is a mere waste product. Not only is the embryo reified, stripped of its human value: it is reduced to the negative condition of an excreta. Just as a laxative is able to rid the lazy colon of its faecal contents, the new pill will free the pregnant uterus from the embryo growing in it. Disconnected from the mother by a neat mechanism of molecular competitiveness between anti-hormones and hormones and catapulted into the sewage system by the action of specific stimulators of the uterine myocyte, the embryo ends its existence without pain or glory. The transmission of human life, the supreme capacity of man to bring men into being, this participation in the creative power of God, will thus become a function of the same physiological, psychological and moral rank as urination or defecation.
The advent of this pill is already being hailed as revolutionary, innovative and liberating. The propaganda that will accompany its commercialisation will be massive and brilliant, and specifically aimed at paralysing the moral conscience of many people. But then the doctor will have to remain faithful to his commitment to respect. An embryo is not a waste product, but a human being, unique and complete in itself. Only respect can inoculate us against the insensitivity and indifference that will numb the conscience of the majority. The practice of medicine will then, more than now, require a great deal of intellectual independence and critical judgement, so that the psychological pressure of the permissive environment, which tolerates everything but dissent, does not corrode the conscience and corrupt the intelligence of doctors.
Respect, and with it the honour of the profession, must be restored. Some may think that when in 1948, in Geneva, in order to make Hippocratic ethics universally acceptable, the Oath was transformed into a promise made for one's own honour, the transcendent sense of the practice of medicine was lost with the reference to God and forever. That seems to me to be a valid interpretation perhaps, but excessively pessimistic. I prefer to think that an honest man, and the doctor must be one, when he promises something for his honour, feels morally bound. There is, it seems to me, a human honesty that has never needed promissory oaths to bind itself to the faithful and sacrificial fulfilment of what it has promised. The Lord, in the Sermon on the Mount, said to his disciples: Let your yes be yes; let your no be no48.
To the students starting their medical studies today, I can assure them that there will always be a need for doctors, many doctors, who, in addition to putting their scientific skill and technical skill skills into the practice of their profession every day, inspire their conduct with the inexhaustible force of this voluntarily embraced precept: "I freely and on my honour promise to maintain the utmost respect for human life from the moment of conception".
Notes
(1) See Pellegrino ED, Thomasma DC. A Philosophical basis of medical practice. Toward a philosophy and ethics of the healing professions. New York, Oxford University Press. 1981, and especially chapter 9: A philosophical reconstruction of medical morality, PP. 192-220.
(2) The most complete anthology of oaths, prayers and codes, with interesting commentary, is found in Etziony MB. The Physician's Creed. An anthology of medical prayers, oaths and codes of ethics written and recited by medical practitioners through the ages. Springfield, Ill. C.C. Thomas, 1973.
(3) See Encyclopedia of Bioethics, edited by WT Reich, New York, The Free Press, 1978. In the appendix: Codes and statements related to medical ethics particular attention is paid to modern times. Neither in Thomas Percival's classic Medical Ethics (Percival's Medical Ethics, edited by CD Leake, Baltimore, Williams & Wilkins, 1927), nor in Félix Janer's Elementos de Moral Médica, Barcelona, J. Verdaguer, 1831, is there any mention of respect.
(4) The official Spanish translation appears in Deontología, Derecho, Medicina. Madrid, Ilustre high school Oficial de Médicos de Madrid. 1977, p. 29. The World Medical Association is preparing an edition of the WMA Handbook of Declarations, which will contain all the Declarations in their three official languages (English, French and Spanish).
(5) committee General de los Colegios Oficiales de Médicos. Código de Deontología Médica. Madrid. Published by the same committee. 1979.
(6) Collegi Oficial de Metges. Normes de Deontologia. Barcelona, 1979.
(7) Colombian Medical Federation. Norms on Medical Ethics. Law 23 of 1981. Voluntary Medical Insurance, no place or date of issue.
(8) International Council of Nurses. Code for Nurses. 1973, reproduced in Reich WT. ed. Encyclopedia of Bioethics, pp. 1788-9.
(9) Lortat-Jacob, JL. Guide Européen d'Etique et de Comportament professionel. Paris. No date of publication. This Guide was presented by Prof. Lortat-Jacob to the International Conference of Medical Orders and Similar Organisations. On 14 January 1980, the Conference adopted the Preamble, which contains the words quoted verbatim.
(10) Lortat-Jacob, JL, o.c. at (9). Due to differences of opinion, the text of the Guide could not be adopted unanimously, although all participants decided that it should be published under the signature of President Lortat-Jacob. Chapter 1 of the Guide: Respect for Life and the Human Person contains the idea of respect as the cornerstone President of medical ethics.
(11) On the specific difference between ethos as a general ethical environment of the profession and Medical Ethics as a formal discipline , see Pellegrino and Thomasma, o.c. in (1), chapter 1: Medicine and Philosophy, pp. 9-38. For a simple presentation, see: Gillon, R. Medical Oaths, declarations and codes. Br Med J 1985; 290: 1194-5, and also Conscience, good character, integrity, and to hell with philosophical medical ethics? Ibid. 1497-8.
(12) Hervada J, Zumaquero JM. Textos internacionales de Derechos humanos. Pamplona, Eunsa, 1978.
(13) Konald D. Codes of Medical Ethics. I History. In Reich WT. o.c. at (3), pp. 162-71.
(14) I think it is interesting to add, in this context, the important "demystifying" effort that textual criticism has applied to the Hippocratic Oath. Alongside the legitimate philological and historical arguments of subject , there has been a frontal attack on the historical significance and practical validity of the precepts included in the oath itself. See in this sense the recently published work by P. Carrick, Medical Ethics in Antiquity: Philosophical perspectives on Abortion and Euthanasia. Dordrecht, Reidel, 1985, which states that medicine never took an innocent life and that Hippocratic precepts were systematically ignored or flouted.
On the significance of the Hippocratic tradition for the general public, see: Ratner H. In search of the Hippocratic tradition. Chicago, Americans United for Life. Law and Medicine series no. 6, undated.
(15) Farley MA. Sexual ethics, in Reich WT, (3), 1586.
(16) Donagan A. The Theory of Morality. Chicago. Chicago University Press, 1979, p. 66.
(17) Laín Entralgo P. La relación médico-enfermo. Madrid. Revista de Occidente, 1964, p. 200. More extensively, Laín himself in his Sobre la Amistad, same publishing house, 1972, deals with this topic in chapter VI: La amistad en el mundo moderno: Kant, pp. 101-121.
(18) Escrivá de Balaguer JM. El respeto cristiano a la persona y a su libertad, in Es Cristo que pasa. 5th ed. Madrid, Rialp, 1973, n. 72.
(19) Richmond JB. Patient reaction to the teaching and reserch situation. J Med Educ 1961; 36: 347-52.
(20) Benarde MA, Mayerson EW. Patient-Physician negotiation. JAMA 1978; 239: 1413-5.
(21) Chawshaw R. Humanism in Medicine. The rudimentary process. New Eng J Med 1975; 293: 1320-2.
(22) See Von Hildebrand D. Sittliche Grundhaltungen. Regensbur: J. Habbel, 1969. In particular, Chapter 1. Ehrfurcht, pp. 9-21.
(23) On philia to man and to the art of healing. v. Laín, La relación... (o.c.) pp. 39-59 which contain a commentary on this famous sentence of the Hippocratic Precepts.
(24) Kessler RH. Gunpowder altered the physician's wartime role. Should nuclear weapons change it again? Arch Intern Med 1983; 143: 784-6.
(25) Article 20 of the Code of Medical Ethics states: "A doctor may refuse to provide his services attendance, when he is convinced that the indispensable relationship of trust between him and the patient does not exist, on condition that he informs the patient or his relatives or friends of this, and ensures the continuity of care and provides all useful information to the doctor who takes his place".
(26) Bolt, RO. A man for all seasons. A play in two acts. New York, Random House, 1962, Preface, pp. xi-xiii.
(27) In this regard, J. Pieper says in his Treatise on the Fundamental Virtues. Prudence, when speaking of the Christian idea of man: Why should there not be demonic linguistic laws in a de-Christianised world, whereby the good appears to man in language as something ridiculous? See also Daly CB, Moral, law and life, Chicago, Scepter, 1966, pp. 15-19, how the technique of persuasive definitions and the deliberate use of the syntagms "that prick" and "that praise" have played a decisive role not only in the philosophical discussion but also in the advertising of the new morality.
(28) Sosnowsky JR. "The pursuit of excellence" Have we apprehended and comprehended it? Am J Obstet Gynecol 1984; 150: 115-9.
(29) "The development of an individual begins with fertilisation". These are the first words of the book by Langman J. Embriología humana. 3rd ed. Madrid. Interamericana, 1976.
(30) With regard to the aggressive, intimidating tone used by some scientific publications against those who disagree with their para-scientific (ethical, for example) views, I think it is interesting to highlight the case of the prestigious journal Nature. The line publishing house, full of passion, contrasts with the scientific soundness of its articles and with the equanimity with which it collects in its correspondence letters from readers who do not share the concepts expressed in its editorial articles and news from the scientific world.
(31) World Medical Association. Statement on Therapeutic Abortion. Oslo, 1970. In Deontology, Law, Medicine, cit. in (4), pp. 45-46.
(32) Cf. Mt. 25, 40.
(33) Smith T. Experiments on embryos: do they have rights? J Roy Soc Med 1985; 78: 503-4.
(34) Réponse des Évéques de Grande-Bretagne au Rapport Warnock. La Documentation Catholique 1985 no. 1893, pp. 392-401.
(35) Report of the Committee of inquiry into Human Fertilization and Embryology. (Chairman Dame Mary Warnock). Cmnd 9314. London: HMSO, 1984.
(36) Report of inquiry into Human Fertilization and Embryology. Medical Research Council's Response. Lancet 1985; i: 270.
(37) Ethics Advisory Board (DHEW). HEW support of research involving human in vitro fertilization and embryo transfer. Washington DC: US Government Printing Office, 1979.
(38) Committee to consider the social, ethical and legal issues arising from in vitro fertilization (Chairman, Louis Waller). Report on the disposition of embryos produced by in vitro fertilization. Melbourne: Government of Victoria, 1984.
(39) Aerztliche, ethische und rechtliche Probleme der Extrakorporalen Befruchtung. In-vitro-Fertilization und Embryo-Transfer. Beschluss. 88. Deutscher Árztetag in Lübeck-Travemünde, 13. May, 1985.
(40) Anonymous. Embryo Research. Lancet 1985; i: 255-6.
(41) Gill PW. Embryo research. Lancet 1985; i: 522.
(42) A nebulous exposition of the uncertainties affecting the gradualist mindset regarding the human condition and the rights of the embryo in Grobstein C. Rights in the womb, in the April 1982 issue of The Sciences, pp. 6-8.
(43) Gleicher N. The fetus is a graft, both biologically and legally. Fertil Steril 1984; 42: 824-5.
(44) Molloy BS. One law for conceptus, one for abortus. Lancet 1984; ii: 231.
(45) Gsell O. Einldhrung in die "Richtlinien zur ärztlichen Ethik" der Schweizerischen Akademie der medizinischen Wissenschaften. Bulí Schweiz Akad Med Wiss 1980; 36: 343-53.
(46) Schooyans M. L'avortement. Approche politique. 3rd edition. Louvain-la-Neuve. Université Catholique de Louvain, 1981.
(47) Early termination of pregnancy by RU 486. Lancet, 1984; ii: 1351.
(48) Mt. 5, 37.